Healthcare Provider Details

I. General information

NPI: 1821174806
Provider Name (Legal Business Name): DEBORAH LOUISE WIDELO PT, MS, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 GREENING LN
WINCHESTER KY
40391
US

IV. Provider business mailing address

PO BOX 4561 340 GREENING LANE
WINCHESTER KY
40392-4561
US

V. Phone/Fax

Practice location:
  • Phone: 859-749-9305
  • Fax: 859-737-3513
Mailing address:
  • Phone: 859-749-9305
  • Fax: 859-737-3513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003026
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number003026
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: